Women who have a family history or have had major depression in the past have a higher risk of becoming depressed in pregnancy and developing a postnatal psychiatric illness which affects approximately 10 to 13% (O’Hara & Swain1996) of all mothers. Puerperal psychosis affects 2: 1000 women (Lewis 2001) and usually occurs early in the puerperium. Non-psychotic postnatal depression has a peak onset of 4 - 6 weeks. Detection not ‘diagnosis’ is aided by use of the Edinburgh Postnatal Depression Scale (EPDS, Cox et al 1989); the Health Visitor will complete an EPDS with all women between 4 – 6 weeks postpartum and again between 3 - 4 months. Baby blues, which occurs 3 - 5 days postpartum, usually resolves spontaneously, it is considered a normal physiological response (Strass 2002), and affects up to 80% of all mothers (Ussher 2004).
The literature suggests that postnatal depression is a normal response to a life event (Murray et al 1995, Paykel 2002). Many researchers argue that there is little to distinguish PND from depression occurring at other times (O’Hara and Zekoski 1988; Watson et al. 1984; Whiffen 1991, 1992; Whiffen and Gotlib 1993 cited by Hagen 1999), with Nicolson (1990) describing it as parallel to a ‘grief reaction’ and part of a normal postnatal profile.
Motherhood, as a ‘rite of passage’ is portrayed by Van Gennep (1909; 1960) as a transitory period that comprises three classic parts; (fig 1)
- Separation from normal life; (Loss)
- Transition a liminal period (on threshold) state of betwixt and between.
- Reincorporation into society with new status; (Adaptation)
(Figure 1.Van Gennep's (1909/1960) conceptualization of the stages of rites of passage (above the line) and the social status of the individual (below the line)
Psychological theories associated with ‘loss’ and ‘adaptation’ are well documented (Kubler-Ross 1970, Parkes 1986, Deits 2000) ‘loss’ for first time mothers (Tarkka et al 1999) has been identified as loss of status, income, adult company, work skills and most importantly loss of ‘self’ (Bandura 1977) and ‘locus of control’ (Rotter 1966 cited by Russell 1999). Deits (2000) confirms that no matter what your loss, it is a loss. Losses, whether they are related to death, ending relationships, or even life events such as getting married, starting a family, and losing your sense of independence, can all affect individuals differently, it is suggested that women during the transition to motherhood experience such losses.
When individuals experience loss, there is usually a period of adjustment; the Kubler-Ross (1970) model of death and dying has five stages, which have been adapted here to illustrate how women may experience grief on the loss of something important to them:
Stage 1. Denial – women could very well be denying their feelings of guilt and disappointment at a time when social expectations are that of ‘a happy event’
Stage 2. Anger - can result from feelings of frustration and loss of control, also because she is giving so much up and is not getting much in return at least not immediately, i.e. sleepless nights, social isolation, loss of personal space and body image.
Stage 3. Bargaining – in attempting to deny the threat posed to ‘self’ conforming to social expectations of the ‘perfect mother’ in order to gain control, i.e. if baby is loved, fed, clean and dry it will be a well contended baby, which means ‘I’m a good mother’.
Stage 4. Depression – sense of helplessness or hopelessness is apparent to the woman although she does not always acknowledge this stage as she may see being depressed as a sign of failure.
Stage 5. Acceptance – acknowledges things are not right and seeks help or agrees to accept help if it is offered by an observer who has identified a health need.
The second stage of Genneps ‘rite of passage’ is transition or liminal period, which means ‘on the threshold’, this is when the woman loses her old status, and before she has taken on her new status. Physically and socially, this could be seen as the period when the woman gives up work and her journey through the process of labour, delivery, and the birth of her baby. Psychologically it could be when the woman herself has fully accepted her new role as a mother: Barr (2001) noted that women suffering PND may find difficulty passing through the ‘rite of passage’ therefore, it could be sometime after the birth before the woman attains reincorporation of her new status in life completing the ‘rite of passage’.
Russell (1999) makes an interesting point about health professionals skills in identifying depression in clinical situations, highlighting how difficult it is to distinguish between what is ‘normal’ and ‘expected’ responses to a given condition. There are of course risk factors that have been identified to assist midwives in their assessment however, there does not appear to be any formal training to facilitate accurate assessments. According to Russell (1999), the Royal College of Physicians and Psychiatrists (1995) recommend urgent action to ensure that health professionals are given the skills to assess and treat depression effectively. Key skills that a midwife would require to practice effectively would be:
- good communication skills and sensitivity when asking questions
- exceptional observational skills
- an empathetic relationship with the women, her partner and family
- a core knowledge of the signs and symptoms of depression
Suggested core knowledge topics are as follows:
- Personality traits like self-efficacy (Bandura 1977 1986) hardiness, mastery and resilience enable people to view life changing events as ‘a positive challenge’ rather than a ‘threat’ or ‘crisis’
- ‘Learned helplessness theory’ (Seligman 1975) a state whereby individuals spiral into a state of depression or hopelessness when repeated attempts to take control of a novel situation have failed.
- ‘faulty thinking’ (Beck 1976; 1987) Beck’s theory is that negative thinking can lead to a depressive state; cognitive behavioural therapy has proved to be a useful treatment in mild to moderate depression, it may even be the treatment of choice (Scott 2001).
The cyclical model of depression (fig 2, Fedouloff) demonstrates the multifactor elements of depression.
(Figure 2)
-
‘biological events’ Studies have shown that rapidly fluctuating hormones (Dalton 1980) and certain brain chemicals called neurotransmitters play an important role in regulating moods and emotions. Neurotransmitters involved in depression include norepinephrine, dopamine, and serotonin (Newport et al 2004); these are also involved in breastfeeding and fluctuate during lactation. Thyroid dysfunction (Harris et al 2002) has also been linked to postnatal depression.
These useful theories related to PND can enlighten midwives understanding of the psychological and biological issues that can lead to postnatal non-psychotic disorders. Risk factors for PND are evident in many research studies (Beck 1996, 2002, O’Hara & Swain 1996, Wilson et al 1996) 75% of well-designed cohort studies (Pope 2000) classified the following factors as being strongly associated with PND:
- History of psychopathology and psychological disturbances during pregnancy or close family member with history of PND
- Low level of social support
- Poor marital/personal relationship
- Recent adverse life experiences such as bereavement, divorce, separation, change of location and or job
- Baby blues" that do not resolve within two weeks of onset.
A study by Hagen (2002) looks at PND from an evolutionary perspective, called the ‘defection hypothesis for PND’; Hagen postulates that women with PND are unconsciously using depression as a defensive response, a bargaining tool. ‘Going on strike’ is an analogy that Hagen uses to explain the ‘human pair bond’ as a cooperative venture where both the mother and father agree to participate in the mutually agreeable role of parenting. Axelrod’s (1984) model of the ‘evolution of cooperation’ illustrates how individuals will develop to provide benefits to others only if they are free to defect from these activities should their costs outweigh their benefits. If the physical and psychosocial costs of nurturing a child outweigh the benefits, mothers will withdraw from this costly venture ‘down tools’, and stop investing in the child, as they have been overwhelmed with their new role and lack of social support. This of course is a simplified version of a complex theory, but one that needs consideration in light of the fact that lack of social support is high on the risk factor scale for developing PND.
During the trigger video, it was evident that many of the women were overwhelmed by the enormity of the transition to parenthood. It seems that the trigger to the onset of PND is when the partner leaves the woman alone to cope with the baby either for a short while or when returning to work. Julie reported having panic attacks at the thought of her husband returning to work holding on to him and begging him not to go. Hagen’s theory (2002) could be applied to this scenario as Julie did ‘go on strike’, because she did not receive the support that she needed, she eventually went to a mother and baby unit and made a good recovery. Barbara who was a registered mental nurse, with no previous history of mental illness, committed suicide after making this last poignant entry in her diary:
“I can’t function without David, never mind look after Laura; I must die”
(BBC 1995).
Is it any wonder that women feel abandoned, isolated, and unsupported; mothers, aunties, sisters, cousins, friends and neighbours, who used to be at home to support women, are now out working, approximately 54--80 percent (Twomey 2001) of women are now in employment. It would appear that motherhood has become an isolating experience for many women. While it is appreciated that fathers are usually the main wage earners during the transition to parenthood financial pressure and limited paternity leave, compels them to return to work. Women could perceive this as a let out for their partners, an escape route, a return to normality, leaving them at home, unsupported with the burden of responsibility. It is also a time that usually coincides with the end of the midwife’s daily visits. Therefore, for the women this could be regarded as the ‘reincorporation’ of their ‘new status’ as mothers; or could it be the insidious onset of non-psychotic postnatal depression; which could prevent them from completing their rite of passage as mothers (Barr 2001).
The focus of this enquiry was to identify an area of antenatal care that would enable the midwife to be a pro-active practitioner. Reviewing current literature and research identified that at the present time there is no evidence to support the early prevention of PND. However, it is suggested that the midwife can improve outcomes in mortality and morbidity while supporting positive mother-baby relationships, not by ‘early interventions’ but by continued postnatal support. This proposal is supported by evidence-based-research from Dennis and Creedy (2004) who conclude that a promising intervention of ‘intensive postnatal support’ provided by midwives is beneficial to women.
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